CM redesign promotes care coordination
Patient satisfaction rises, avoidable days decrease
A new case management model that establishes hospitalwide care coordination and promotes collaboration among disciplines is paying off for Alamance Regional Medical Center in Burlington, NC.
In the new model, traditional case management duties are shared by clinicians in the separate roles of admissions nurses, care coordinators, social workers, documentation specialists, utilization review staff, and the patient care nurses.
The admissions nurses review each admission for medical necessity and level of care required. Care coordinators are responsible for ensuring that patients' needs are met efficiently and effectively. The social workers handle the complicated discharges and other social issues while the documentation specialists work with coders to ensure that documentation is accurate and complete, and the utilization review staff are responsible for UR for commercial patients.
Already the new model, which is still being rolled out throughout the hospital, has reduced avoidable days and increased patient satisfaction, says Beve Butler Smith, RN, MSN, CHCC, director of care management for the 238-bed regional hospital.
"In addition, communication between the staff is much better. In the units where the new model is fully rolled out, I can see an excitement between the care coordinators and the rest of the staff that wasn't there before," she says.
When patients come into the hospital, the admissions RN reviews the admission for medical necessity and patient status using InterQual criteria and assigns a DRG before the patient is admitted. The nurse puts the data into the hospital's electronic system, which assigns a geometric length of stay.
If the patient record doesn't support medical necessity criteria for the admission, the nurse contacts the physician and asks for additional information.
If the admissions nurse and the physician can't agree on inpatient admission versus observation, the nurse refers the case to a physician advisor who reviews the medical record and either affirms the admission or contacts the admitting physician for more information.
If the additional documentation still doesn't support an inpatient admission, the nurse informs the patient and family and makes sure they understand what their financial responsibility is likely to be.
"The nurse talks to the patient and family while they still are in the emergency department and explains the difference between inpatient and observation services. We give them a written notice that they are in observation and what it means, including the fact that they will have a copay," she says.
If the nurse suspects that the services the patient will receive may not be covered, she gives them a Hospital-Issued Notice of Non-Coverage (HINN) letter and explains what it means.
The admissions nurses go through the same process with patients coming in from the emergency department, patients being directly admitted, those receiving same-day surgery who aren't ready to be discharged, and patients from the cancer center who may need inpatient treatment.
"Any patient who needs a room goes through an admission review," Smith says.
During the admissions process, the nurse talks to the patient about his or her expectations for the hospital stay and goals for discharge.
"Patients are becoming more involved in their care and often want to talk about their discharge goals and destination up front. If it appears they may need post-acute services, we discuss it with them and ask them to think about what they want and where. This gives us the beginnings of a discharge plan as we admit the patients," she says.
Admissions nurses cover the hospital from 7 a.m. to 11 p.m., seven days a week. If patients come in after 11 p.m., the nurse reviews the records immediately at 7 a.m.
"During the times the admission nurses are not in the house, it's often obvious that the patient needs to be admitted. If it's not clear, they are placed in observation and the record is reviewed by the nurse when she arrives," Smith says.
Under the new model, RN care coordinators are responsible for coordinating care for the patients, performing utilization review and continued stay review for Medicare patients, and handling simple discharges. Social workers assist with the utilization review for Medicare patients and handle all the complicated and challenging discharges.
The care coordinators no longer are responsible for patient status, assigning DRGs and anticipated discharge dates or performing documentation assurance.
Each care coordinator is unit-based and manages the care for about 25 patients. The hospital is staffed with one social worker for every 40 patients.
Having unit-based care coordinators gives the nurses an opportunity to become familiar with the patient population on the unit, and to develop a close working relationship with the physicians and the rest of the staff on the unit, Smith points out.
"With this model, the care coordinators spend a great portion of their time with the patients, doing rounds, and keeping everything going smoothly. They coordinate all the ancillary services so everything gets done in a timely manner," she adds.
The care coordinators are responsible for tracking patients who are receiving observation services and making sure they are either discharged or admitted within 24 hours.
They make rounds on each patient four times during the day.
Every day at 10 a.m., the care coordinator and shift coordinator (charge nurse) make "touch-base" rounds, usually at the nursing desk or in the break room.
They talk about each patient on the unit, looking at the reason for admission and the anticipated discharge date, and set goals for the day, then determine who will be responsible for ensuring that the goal is met.
The care coordinators use an electronic care coordination review tool that guides them during the rounds to ensure consistency.
"Our rounds are very structured. We don't just look at a patient, say they're doing well, and move on. The care coordinators and shift coordinators thoroughly review the patient record, looking at the core measures, and the major systems on every patient every day. It helps us develop our goals and work through what we need to do to accomplish them," she says.
Right after the touch-base rounding, the care coordinator visits the patients. They identify themselves, write the goals for the day on a white board in the patient's room, and discuss the goals with the patient, including what he or she needs to do to participate in meeting the goals.
For instance, if one of the goals for the day is removing the patient's Foley catheter, the care coordinator tells the patient he or she should drink a lot of water to prepare.
Later in the day, the care coordinator rounds with the physician in the patient's room and brings up the goals for the day and what the patient is doing to help meet the goals. The care coordinator and the physician also talk about the discharge plan for the patient and what has to happen before the patient can go home.
The shift coordinator and care coordinator meet again for touch-base rounds at 2:30, review each patient again, and make sure the goals were met.
The care coordinators handle the simple discharges and refer patients who have complicated discharge plans to the social worker as early in the day as possible.
"The number of challenging discharges has tripled in the last two years. The number of patients who have no place to go is huge. The social workers handle the discharges for patients who need IV therapy after discharge, who have no insurance coverage for medication, who are homeless, or have other social needs," she says.
The case managers and social workers handle utilization review and continued stay review for the Medicare patients.
The hospital created a separate department to handle utilization review for commercial payers. Documentation specialists, who are RNs or social workers, work with the coders to ensure that the documentation is complete and accurate.
"There's so much money riding on documentation these days that we felt like we needed a separate staff whose sole responsibility is documentation assurance," she says.
The documentation specialists and coders funnel all queries to the physician through the care coordinator, who brings up the subject during rounds.
"We didn't want to overwhelm the doctors with questions, so everyone sends their queries to the case manager, who already has a good working relationship with the physicians," she says.
Before the redesign, the hospital had an integrated model of case management and social work.
"The case managers and social workers worked together in tandem, and there wasn't much difference in their jobs. Both did discharge planning. The social workers had been cross-trained to assign DRGs and to perform admission and continued stay reviews using InterQual," Smith says.
But as regulations changed dramatically, the Centers for Medicare & Medicaid Services (CMS) rolled out the Recovery Audit Contractor (RAC) program and other initiatives to scrutinize hospital reimbursement, and the hospital administration realized that the work of the case management department needed to be realigned in order to continue to get optimum reimbursement under pay-for-performance initiatives.
"The RACs started looking at our efficiency in a new way. We know that we are doing a good job and providing high-quality patient care, but if we can't document it, we could come out on the losing end. The challenge in today's health care environment is making sure that we are providing care efficiently and in the correct environment, and at the right time, and that we are carefully describing it in the medical record. If we don't carefully document everything we do and the services aren't provided at the right level of care, we are not going to realize the reimbursement we deserve for the great services we provide," Smith says.
The core group that developed the new model included the directors of patient financial services, health information management, case management, the medical director, and the head of the hospitalist team. Representatives from human resources and patient relations were called in as needed.
The team put together a timeline and worked with patient relations to coordinate education on the process.
The hospital leadership met with the entire case management staff and described the new model. The existing staff were given the option to choose where they wanted to work.
Working with the human resources department, the leadership team wrote job descriptions for the new roles. They set up interviews with the staff to help them make choices about which job they preferred.
The hospital leadership team spent a lot of time educating everyone at the hospital on why the emergence of pay for performance makes it necessary for everyone to change the way they work, Smith says.
"If hospitals are going to survive all the regulations and reimbursement challenges of today, we have to look at patient safety, quality, efficient throughput, and documentation as universal challenges, and not just the responsibility of care management or a single department. The staff in ancillary services need to understand that when a patient needs a consultation, test, or procedure in order to move along the established plan of care for discharge, we need to work together and get it done even if the schedule is full. Physicians need to understand that with the MACs [Medicare Administrative Contractors] and MICs [Medicaid Integrity Contractors], documentation is everybody's problem because they are going to be penalized financially if we don't tell the patient's story in the medical records," Smith says.
"Care coordination is the process to help the acute care environment share a goal with a patient and make it happen," she says.
[For more information contact: Beve Butler Smith, RN, MSN, CHCC, director of care management, Alamance Regional Medical Center, e-mail: [email protected].]
A new case management model that establishes hospitalwide care coordination and promotes collaboration among disciplines is paying off for Alamance Regional Medical Center in Burlington, NC.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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